1. Sedation and analgesia in the ICU
Dr Jeju Nath Pokharel, MD
Sr consultant anesthesiologist and
Head Dept of Anesthesiology
SGNHC, Bansbari, Kathmandu, Nepal
Sedation and Analgesia in the ICU
Dr Jeju Nath Pokharel
Senior consultant anaesthesiologist
SGNHC, Bansbari Kathmandu Nepal.

2. Some definitions
Pain – It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Analgesia - is defined as the blunting or absence of sensation of pain or noxious stimuli. (ACCM 2002)
Anxiety - a sustained state of apprehension with accompanying autonomic arousal in response to a real or perceived threat.
Delirium – an acute, potentially reversible impairment of consciousness and cognitive function that fluctuates in severity.
Agitation – it is characterized by extreme arousal,irritability, excess motor activities driven by internal sense of discomfort such as disease, pain, anxiety and delirium.
Pain – It is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Analgesia - “analgesia” is defined
as the blunting or absence of sensation
of pain or noxious stimuli.- ACCM 2002
Anxiety - a sustained state of apprehension with accompanying autonomic arousal in response to a real or perceived threat.
Delirium – an acute, potentially reversible impairment of consciousness and cognitive function that fluctuates in severity.
Agitation – it is characterized by extreme arousal,irritability, excess motor activities driven by internal sense of discomfort such as disease, pain, anxiety and delirium.

3. Background
One third of all patients in intensive care units (ICUs)worldwide are mechanically ventilated.
Common conditions in mechanically ventilated, critically ill, trauma patients are acute pain, anxiety, and delirium.
ICU patients frequently experience pain and physical discomfort from obvious factors, such as pre-existing diseases, invasive procedures, or trauma. Pain and discomfort also can be caused by:
- monitoring and therapeutic devices such as catheters, drains, and endotracheal tubes
- performing routine nursing care (e.g., airway suctioning, physical therapy, dressing changes, patient mobilization)
-prolonged immobility.
Background
One third of all patients in intensive care units (ICUs)
worldwide are mechanically ventilated.1 Common
conditions in mechanically ventilated, critically ill,
trauma patients are acute pain, anxiety, and
delirium.2
ICU patients frequently experience pain and physical
discomfort from obvious factors, such as pre-existing
diseases, invasive procedures, or trauma. Pain and
discomfort also can be caused by:
• Monitoring and therapeutic devices such as
catheters, drains, and endotracheal tubes
• Performing routine nursing care (e.g., airway
suctioning, physical therapy, dressing changes,
patient mobilization)
• Prolonged immobility.3

4. Background
unrelieved pain may contribute to inadequate sleep and disorientation, and evoke a stress response, decreased cell repair cellular immunity.
Severely ill patients in a stressful environment for prolonged periods may also experience delirium.
Delirium itself is attributed to increased length of hospital stay, increased health care costs, and higher mortality.
Additionally, the ICU patient may experience heart, lung, liver, and kidney complications, Post Traumatic Stress Disorder (PTSD), and long-term cognitive decline.

5. Background
Safe and effective management of an ICU patient’s pain and anxiety demands a delicate balance of analgesia and sedation protocols while managing delirium.
Safe and effective management of an ICU
patient’s pain and anxiety demands a delicate balance
of analgesia and sedation protocols while managing
delirium

6. Why sedation and analgesia is required ?
To improve patient comfort.
Reduce stress.
Facilitate interventions.
Allow effective ventilation/oxygenation.
Encourage natural sleep.
?? Prevent post-ICU psychosis.
Why sedation is required ?

7. Sedation comes from the Latin word sedare.
Sedare = to calm or to allay fear
Hypnosis
Analgesia
± Muscle
Relaxation

8. Balancing Pain and Anxiety Treatment
Reduces pain, decreases anxiety, manages delirium, makes pt amnesic to ICU events and leads to smooth recovery.
Reduces hospital stay and cost.

9. PROMOTE NATURAL SLEEP CYCLE
Allow natural sleep at night
Stick to the schedule for sleep.
Avoid frequent waking tasks and prevent
interruptions.
Use back massage to relax the patient for sleep.
Create a quiet, dark environment conducive to sleep as much as possible, lessen outside lighting, turn off lights including flashing indicators, and reduce human and mechanical noise.
Use natural sleep cues ( lighting, noise, smells, room with windows which can mimic 24 hour day to regulate day light /darkness.
Use music therapy to encourage sleep.
Facilitate patient’s familiarity with environment.
PROMOTE NATURAL SLEEP CYCLE:
Allow natural sleep at night.
Stick to the schedule for sleep.
Avoid frequent waking tasks and prevent
Use back massage to relax the patient for sleep.
Create a quiet, dark environment conducive to sleep.
As much as possible, lessen outside lighting, turn
off lights including flashing indicators, and reduce
human and mechanical noise.
Use natural sleep cues . When establishing the
patient’s sleep at night, use natural sleep cues,
such as lighting, noise, and smells. If possible,
provide a room with a window or provide lighting
that mimics the 24 hour day to help patients
regulate to daylight/darkness.
Use music therapy to encourage sleep.
Facilitate patient’s familiarity with environment.

10. Employ comfort measures:
• Provide complementary holistic therapies • Encourage family to stay at bedside • Remove unnecessary lines and tubes • Remove or minimize restraints • Encourage family to be at the bedside and engage the patient in activities as well as sitting quietly with the patient to promote rest
Employ comfort measures:
• Provide complementary holistic therapies
• Encourage family to stay at bedside
• Remove unnecessary lines and tubes
• Remove or minimize restraints
• Encourage family to be at the bedside and engage the
patient in activities as well as sitting quietly with the
patient to promote rest

11. PATIENT ASSESSMENT
PATIENT ASSESSMENT

12. PATIENT ASSESSMENT
PATIENT ASSESSMENT

13. Pain
Pain is an unpleasant sensory or emotional experience that is associated with tissue damage or described in terms of tissue damage. (International Association for the Study of Pain,
All critically ill patients have the right to adequate analgesia and management of their pain.
A patient’s pain experience in the ICU need not be
memorable given effective attention and application of pain management and amnesic agents.
Pain - Pain is an unpleasant sensory or emotional experience that
is associated with tissue damage or described in terms of
tissue damage. (International Association for the Study of Pain
Retrieved November 2009)

14. Self reporting pain assessment scale: Wong –Baker FACES Pain rating scale

15. Non – verbal reporting of pain: 10 point non – verbal pain scale.

16. Non verbal reporting of pain: The Critical-Care Pain Observation Tool (CPOT)

17. Pain management algorithm

18. Some analgesics

20. Sedation
Sedatives are drugs that calm a patient down, easing agitation and permitting sleep.
Sedatives generally work by modulating signals within the central nervous system.
The appropriate target level of sedation is a calm patient that can be easily aroused with maintenance of the normal sleep-wake cycle (SCCM).
Advantage/disadvantage
Robinson et al (2008) found continuous sedative infusions for critically ill patients have been shown to increase the duration of mechanical ventilation and length of intensive care stay, despite perceived advantages.
coordinated daily interruption of sedative infusions with objective re- titration in critically ill patients has been shown to decrease the durations of mechanical ventilation and length of ICU stay.

21. Sedation assessment scales
Richmond Agitation Sedation Scale (RASS)
RASS Target Sedation = 0 to -3
Riker Sedation-Agitation Scale (SAS)
SAS Target Sedation = 3 to 4
Ramsay scale ( RS )
VICS (Vancouver Interaction and Calmness Scale)
MAAS (Motor Activity Assessment Scale)
The AVRIPAS scale
The BLOOMSBURY Scale
HS (Harris Scale)
ATICE (Adaptation to the Intensive Care Environment).

22. Sedation assessment scales

23. Sedation assessment scale

24. Sedation assessment scales
RS (Ramsay Scale):
Level Response
Awake and anxious, agitated, or restless
Awake, cooperative, accepting ventilation, oriented, tranquil
Awake; responds only to commands
Asleep; brisk response to light glabellar tap or loud noise
Asleep; sluggish response to light glabellar tap or loud noise stimulus but does not respond to painful stimulus
Asleep; no response to light glabellar tap or loud noise
Figure . The Ramsay Scale. Modified from Ramsay M, Savege T, Simpson BRJ, et al. Controlled sedation with alphaxalone/alphadolone. BMJ 1974;2:656–569.

25. Non pharmacological methods of sedation
environment modification,
relaxation, back massage, and music therapy when appropriate.
Non pharmacological methods of sedation
environment modification,
relaxation, back massage, and music therapy when
appropriate.

26. Pharmacological method of sedation

27. Pharmacology of selected sedatives

28. Daily awakening trial
A Daily Awakening Trial (or Sedation Vacation) is titrating down continuous infusions of sedatives or holding sedation bolus until the patient is awake
Once the patient is awake and responsive, an accurate sedation, pain, and delirium assessment can be obtained
It is recommended to couple spontaneous breathing trial protocols with sedation protocols
combining a spontaneous breathing trial protocol with a daily wakening trial results in patients spending less time on mechanical ventilation, less time in coma, and less time in intensive care and the hospital.
DAILY AWAKENING TRIAL
A Daily Awakening
Trial (or Sedation
Vacation) is titrating
down continuous
infusions of sedatives
or holding sedation
bolus until the patient
is awake.
Once the patient is awake
and responsive, an
accurate sedation, pain,
and delirium assessment
can be obtained.

29. Daily Awakening Trial and Spontaneous Breathing Trial

30. SEDATIVE AND ANALGESIC WITHDRAWAL
Benzodiazepines
dysphoria,
tremor,
headache,
nausea,
sweating,
fatigue,
anxiety,
agitation,
increased sensitivity to light and sound,
paresthesias,
muscle cramps, myoclonus,
sleep disturbances,
delirium, and
seizures.
Opioids
dilation of the pupils
sweating,
lacrimation
rhinorrhea,
piloerection
tachycardia,
vomiting,
diarrhea,
hypertension,
yawning,
fever,
tachypnea,
restlessness,
irritability,
increased sensitivity to pain,
cramps, muscle aches,
anxiety.
SEDATIVE AND ANALGESIC
WITHDRAWAL
Opioid withdrawal
signs and symptoms include dilation of
the pupils, sweating, lacrimation, rhinorrhea,
piloerection, tachycardia, vomiting,
diarrhea, hypertension, yawning, fever,
tachypnea, restlessness, irritability, increased
sensitivity to pain, cramps, muscle
aches, and anxiety.
Benzodiazepine
withdrawal signs and symptoms include
dysphoria, tremor, headache, nausea,
sweating, fatigue, anxiety, agitation, increased
sensitivity to light and sound,
paresthesias, muscle cramps, myoclonus,
sleep disturbances, delirium, and seizures.

31. DELIRIUM
Delirium, characterized by fluctuations in mental status such as inattention,disorganized thinking,hallucinations, disorientation, and an altered level of consciousness, is a frequent occurrence in the intensive care unit (ICU).
Occurs in up to 65 percent of hospitalized patients, and up to 87percent of patients admitted to the ICU.
Hyperactive delirium, Hypoactive delirium, Mixed delirium
Delirium, characterized by fluctuations in mental
status such as inattention, disorganized thinking,
hallucinations, disorientation, and an altered level
of consciousness, is a frequent occurrence in the
intensive care unit (ICU).
occurs in up to 65 percent of hospitalized
patients, and up to 87percent of patients admitted to
the ICU.

32. Agitation & delirium: an aide memoire for routine use
I WATCH DEATH
Infection
Withdrawal
Acute metabolic problem
Trauma/ pain
CNS pathology
Hypoxia/Hypoglycemia
Deficiencies (B1, B12)
Endocrinopathies
Acute vascular
Toxins/ drugs
Heavy metals
DELIRIUM
Drugs
Electrolyte abnormalities
Lack of drugs
Infection
Reduced sensory input
Intracranial problem
Urinary retention & fecal impaction
Myocardial infarction

33. Drugs that can cause Delirium
Anti-arrhythmics
Lidocaine
Mexilitine
Quinidine
Antibiotics: Penicillin
Anti-cholinergics: atropine
Anti-histaminics
Beta-blockers: propranolol
Narcotics: meperidine
Morphine
Pentazocine
Drugs that can cause Delirium

34. Delirium Assessment (CAM-ICU) Algorithm

35. Intensive Care Delirium Screening Checklist (ICDSC)

36. Risk Factors for Delirium
Delirium in patients usually develops between 24 and 72 hours after admission to ICU.
Risk factors before hospitalization: cognitive impairment, chronic illness (including hypertension), advanced age (over 65 years), depression, smoking, alcoholism, and severity of illness.
Risk factors during hospitalization: Congestive heart failure, sepsis, prolonged restraint use and immobility, withdrawal, seizures, dehydration, hyperthermia, head trauma, intracranial space-occupying lesions, and the use of specific medications: LORazepam/ Midazolam, Morphine/fentanyl, and Propofol.
Risk Factors for Delirium
Delirium in patients usually develops
between 24 and 72 hours after admission to
ICU.
Risk factors before hospitalization:
cognitive impairment, chronic illness
(including hypertension), advanced age
(over 65 years), depression, smoking,
alcoholism, and severity of illness.
• Risk factors during hospitalization:
Congestive heart failure, sepsis, prolonged
restraint use and immobility, withdrawal,
seizures, dehydration, hyperthermia, head
trauma, intracranial space-occupying
lesions, and the use of specific
medications: LORazepam/ Midazolam,
Morphine/fentaNYL, and Propofol.

37. Delirium Management Algorithm

38. Conclusion ICU sedated pt care map
ICU sedated patient care map.

39. Thank you for attention !